Gender Bias in Medicine

Abstract

Gender bias has implications in the treatment of both male and female patients and it is important to take into consideration in most fields of medical research, clinical practice and education. Gender blindness and stereotyped preconceptions about men and women are identified as key causes to gender bias. However, exaggeration of observed sex and gender differences can also lead to bias. This article will examine the phenomenon of gender bias in medicine, present useful concepts and models for the understanding of bias, and outline areas of interest for further research.

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PERSPECTIVE
10.2217/17455057.4.3.237 © 2008 Future Medicine Ltd ISSN 1745-5057 Women's Health (2008) 4(3), 237–243 237
part of
Gender bias in medicine
Katarina Hamberg
Umeå University,
The Department of Public
Health & Clinical Medicine,
Family Medicine, & Centre
for Gender Excellence at
Umeå University, Research
Programme Challenging
Gender, 901 85 Umeå,
Sweden
Tel.: +46 90 785 3534;
Fax: +46 90 126 886;
E-mail: katarina.hamberg@
fammed.umu.se
Keywords: doing gender,
gender bias,
gender stereotypes,
medical research, sex
Gender bias has implications in the treatment of both male and female patients and it is
important to take into consideration in most fields of medical research, clinical practice
and education. Gender blindness and stereotyped preconceptions about men and women
are identified as key causes to gender bias. However, exaggeration of observed sex and
gender differences can also lead to bias. This article will examine the phenomenon of
gender bias in medicine, present useful concepts and models for the understanding of bias,
and outline areas of interest for further research.
Research has shown that different biological
processes, anatomies, conditions in daily life,
environmental experiences, risk behaviors and
responses to stressful events, may all contribute
to variation in health and disease in men and
women [1–5]. There is also evidence that women,
for no apparent medical reason, are not offered
the same treatment as men, a phenomenon that
raises the question of gender bias. Many studies,
for example, show that women are less likely
than men to receive more advanced diagnostic
and therapeutic interventions [6–11].
The word bias means ‘prejudice’ or ‘distortion’
and is a threatening phenomenon in all kinds of
research and human activity. When we talk about
gender bias in medicine we usually either mean
an unintended, but systematic neglect of either
women or men, stereotyped preconceptions
about the health, behavior, experiences, needs,
wishes and so on, of men and women, or neglect
of gender issues relevant to the topic of interest.
Gender bias has implications in treatment of
both male and female patients and it is important
to take into consideration in most fields of medi-
cal research, clinical practice and education.
Gender bias is also a relevant issue in the discus-
sion of clinical and academic advancements and
careers [12]; however, that aspect is not the focus
of this article. Since there is confusion in medi-
cine about the use of the concept of gender [13],
my use of the term is presented below.
Sex & gender
In gender research, sex and gender are distinct
concepts. Generally, while sex signifies biological
characteristics in men and women, for example
chromosomes, hormones and reproduction, gen-
der describes variability between men and
women that is attributable to society and culture.
The ‘gender order’ in society means that a
‘normal’ human being is assumed to be a man,
women as a group are regularly subordinated to
men, and boys and men are seen as being more
important and valuable compared with girls and
women [14]. The gender order implies that social
determinants such as economic wealth, educa-
tion, and political power, are unequally distrib-
uted between men and women. The concept of
gender also refers to the constantly ongoing
social construction of what is considered ‘femi-
nine’ and ‘masculine’ and is based on power and
sociocultural norms about women and men.
Seen in this way, gender is constantly created in
interaction between people, we are all ‘doing
gender’ [15]. In the patient–doctor interaction,
the patient is ‘doing gender’ by presenting herself
or himself in line with what is seen as acceptable
for each gender; and the male or female doctor
does the same. The construction of gender
involves the actor(s), such as patients who
present their symptoms, as well as the
observer(s), doctors who interpret the patients’
narratives and behaviors.
In medicine, the dichotomy between sex and
gender might cause problems. Biological and
social aspects are related and the explanation of a
patient’s health problem can seldom be ascribed
to only one of the categories [16]. For example, on
a population level men have heavier bones than
women but there are large differences within the
two populations. Teenage girls who exercise are
‘doing gender’ differently compared with girls
who are not physically active and these two
groups will develop bones and bodies that differ.
Many girls who exercise will probably have heav-
ier bones than boys who do not exercise [17]. In
bone building, what should be referred to sex
and what should be ascribed to gender? A gender

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perspective in medicine implies that men and
women’s life conditions, life styles and positions
in society, as well as societal expectations about
‘femininity’ and ‘masculinity’, are considered
along with biology.
Gender bias in clinical practice
In a large variety of conditions, such as coronary
artery disease [8,11,18], Parkinson’s disease [9], irri-
table bowel syndrome [19], neck pain [20], knee
joint arthrosis [21] and tuberculosis [10], men are
investigated and treated more extensively than
women with the same severity of symptoms. In a
recent study of treatment in psoriasis, the
number of patients and the severity of the disease
did not differ between men and women, yet
there was far more expenditures for clinic-based
treatment for male patients, than female patients
who received emollients for self-care to a greater
extent [22]. In a retrospective study of intensive
care use, large disparities were found between
men and women [23]. Specifically, older women
(aged 50 years or older) were less likely than
older men (with similar severity of illness) to be
admitted to intensive care units or receive life-
saving interventions. Research indicates that
physicians are more likely to interpret men’s
symptoms as organic and women’s as psycho-
social [24,25], and female patients are assigned
more nonspecific symptom diagnoses [20,26].
Women are also prescribed more psychoactive
drugs than men [27,28].
In most of the studies referred to above, it is
difficult to know the extent to which gender dif-
ferences in management reflect the gender bias
of physicians, or is due to other physician,
patient or communication characteristics related
to gender [29,30]. For example, the biological dif-
ferences between men and women might imply
that the type and severity of symptoms vary, thus
explaining the differences in treatment [4].
Patients’ wishes and communication behavior
are other suggested reasons for the gender differ-
ences in the medical process [3,18,31]. It is, for
instance, argued that men describe their
symptoms in a straightforward and demanding
way, while women often give vague symptom
descriptions and hesitate to accept potentially
dangerous measures such as surgery [9,21].
However, gender differences in diagnosis and
treatment are also found in studies of the medi-
cal management of male and female ‘paper-
patients’ or ‘video-vignettes’, situations where
the influence of patient behavior and interaction
between patient and doctor are controlled
[7,19,20]. In such studies, it is hard to explain the
differences in terms other than gender bias as a
result physicians’ lack of awareness about gender,
stereotyped expectations about health and needs
in men and women, or a routine-like application
of statistical sex or gender differences on individ-
ual patients. The roots of gender bias in clinical
work might also be found at a system level [32],
which is to say in the healthcare organization or
routines, or in distorted content in established
medical knowledge.
Gender blindness in research
The custom of performing clinical trials on pop-
ulations consisting exclusively or mainly of
young or middle-aged white men, and generaliz-
ing the results to whole populations has been
criticized since the 1970s as a way of producing
biased knowledge.
In order to correct the gender imbalance in
research populations, the influential NIH in the
USA issued guidelines in 1990 requiring the
inclusion of women in all NIH-sponsored clini-
cal research. Since 1994, the NIH has also
required analyses of trial outcomes by sex. Nev-
ertheless, even if scientific journals are more
aware of sex/gender nowadays, there are still
many recommendations about treatments and
drugs that are based on studies where the major-
ity of participants were men [33–37]. It is equally
common that no sex-based analyses are per-
formed even though both men and women are
enrolled, or that too few women (or men) were
included to allow for sex-based analyses. This
means that gender blindness has still not been
eradicated and a great deal of contemporary
knowledge about diseases and risk factors is con-
structed without considering the relevance of
either sex or gender.
Advancements
Even if gender blindness is still a problem, huge
efforts have been made by some researchers to
counteract the neglect of women and support
medical science with data on women [1–4]. To
date, this research has been fruitful and has
shown its potential mainly concerning differ-
ences and similarities in cardiovascular diseases
(CVDs) [38,39]. It is, for example, now acknowl-
edged that myocardial infarction without plaque
is more common in women than men and this
has consequences for the investigations required
to secure a patient’s diagnosis [39,40]. Recently,
evidence-based guidelines for cardiovascular dis-
ease prevention in women were presented [41].

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With few exceptions these recommendations did
not differ from those for men. However, the use
of the term ‘evidence-based’ signifies that there is
now a substantial amount of research performed
on the issue of CVD prevention in women,
making it possible to rely on scientific knowl-
edge about women instead of just transferring
knowledge about men to guidelines for women.
Other examples of gender
bias in research
Looking beyond gender blindness and probing
into the awareness of gender in research, implies
posing new and critical questions and scrutinizing
concepts generally taken for granted. I will give
examples of bias risks concerning the common
concepts; depression, sex hormones, and maleness
and femaleness. The first example challenges the
reliability of the depression diagnosis.
Throughout the western world, depression is
regularly reported as being twice as common in
women as in men [42]. The higher prevalence of
depression in women has been ascribed to social
and cultural living conditions, for example,
many women suffer sexual and physical abuse, as
well as biological processes, primarily processes
involving estrogen and progesterone. At present,
the connection between women and depression
is fuelling a great deal of research into biological
mechanisms in women [4,42,43].
However, according to Hirschbein, there is rea-
son to scrutinize the very concept of depression [44].
In her medical history research, she found that
even before depression was described and estab-
lished as a diagnosis in Diagnostic and Statistical
Manual of Mental Disorders-III, psychiatrists
assumed that women were more often depressed
than men. Between the 1950s and the 1980s
researchers studied hospitalized patients whose
symptoms were counted and used to define a cat-
egory of depression. The patients studied were
mostly women because there were more women
than men with assumed depression in the hospital
wards. In addition, patients who abused drugs
and alcohol, the majority of them being men,
were regularly excluded from the studies. This
means that the connection between women and
depression has become a closed circle: researchers
studied mainly women to establish the grounds
for the diagnosis, thus more women fitted into
the descriptions and received the diagnosis, which
in turn supported conclusions that more women
than men are depressed. Inasmuch as the con-
struction of the depression diagnosis inherited
gender-biased assumptions, these biased beliefs
affect research and clinical practice even today
[2,42,44]. Furthermore, it has been shown that men
who score high on depression scales are less likely
to be diagnosed as depressive than women with
similarly high scores [45]. This shows that physi-
cians’ preconceptions about a gendered pattern of
depression are also biased to the interpretations of
standardized data.
Realizing that depression is a diagnosis
reframed by gender bias, how can we then assess
the fact that billions of antidepressant pills are
prescribed to women (and maybe withheld
men) of all ages? More critical research is needed
about gender and mental illness, such as the use,
misuse and side effects of medication in relation
to gender.
The second example concerns the concept of
sex hormones. In the years between 1920 and
1940, hormone research had a heyday [46].
Researchers learned how to purify active factors
from testes and ovaries and how to produce crys-
tals of steroid hormones. In this process they
gave the hormones names, which reflected their
structures and assumed biological functions.
During the steps toward isolation, measurement
and naming, the researchers made scientific deci-
sions that were understood as biological truths
about sex; there are two sex characters and two
sex hormones defining maleness and
femaleness [46]. The definitions were, however,
based on stereotyped ideas about gender, and the
notion that the hormones extracted from testes
and ovaries were closely linked to maleness and
femaleness, respectively. This labeling of estro-
gens and androgens as sex hormones has dis-
torted our thinking about them and probably
also delayed progress in the research. For exam-
ple, when excretion of estrogenic hormone was
identified in urine from stallions in the 1930s,
this finding was interpreted as being caused by
contaminations. Although hormone researchers
today label androgens and estrogens ‘growth hor-
mones’, and investigate their effects in both men
and women, estrogens and testosterone are still
often called ‘sex hormones’ in medical literature
and in clinics [47].
The third example concerns a similar prob-
lem. According to my own experiences, the con-
cepts of maleness and femaleness have to be used
with caution since they also carry with them a
risk of creating blind spots and circular proofs.
Naming a specific feature or behavior as mascu-
line implies loading it with preconceptions and
notions that render it hard to identify in
women. When a so-called ‘masculine behavior’

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is identified in women this might easily be seen
as an exception or something very interesting.
Thus, to reduce the risk of bias in research it is
important to choose labels that are not loaded
with gendered preconceptions, because such
labels reinforce the risk of producing distorted
interpretations and results.
Knowledge-mediated gender bias
Although more knowledge is crucial to eradicate
mistreatment and bias as a result of gender blind-
ness and ignorance, availability of facts and
information is no safeguard against bias. Despite
the many publications about gender bias in
treatment and investigations of cardiovascular
diseases, inappropriate treatment of women is
regularly reported even today [7,8,11]. Further-
more, once we learn about differences between
populations of men and women a new kind of
risk occurs on the individual level, the risk of
‘knowledge-mediated bias’ [19]. For instance, it is
well known that hypothyreosis is less common in
men than women. Thus, the risk that physicians
fail to investigate thyroxin levels is greater in
male than in female patients, when patients
complain of tiredness, loss of energy, constipa-
tion or other vague symptoms that might be
caused by hypothyreosis.
Another aspect of knowledge-mediated bias is
described in relation to the pharmaceutical
industry, the information they give out and their
marketing activities. For example, migraine is a
disorder that affects millions of people, three-
quarters of them being women [4]. Based on this
fact the pharmaceutical industry portrays pre-
dominantly female patients in direct-to-con-
sumer advertisements, as well as advertisements
directed to doctors, thereby reinforcing the
impression that migraine is a ‘women’s
disorder’ [48]. An audience consisting of female
patients is constructed while millions of male
patients are ignored. It is hardly surprising then,
as in the case of hypothyreosis, that male patients
with migraine are less often correctly diagnosed
when they consult a doctor [49].
A two-way view of gender bias
Ruiz and Verbrugge presented a useful model for
understanding gender bias in the delivery of
health services and research [29]. One view assumes
that health situations and risks are similar for
women and men, when in fact they are not, while
the other view assumes differences between men
and women when there actually are similarities.
According to the authors, the views originate in
the biomedical model that assumes similarities in
the case of physical health problems and differ-
ences when it comes to emotionally toned
problems and self-expressed health.
This two-way view represented a step forward
since it is emphasized that bias is not only based
in gender blindness and implicit ideas about
similarities, but might also rely on stereotypical
preconceptions about men and women being
different, or on an overestimation of observed
differences. One example of the latter was pre-
sented in a recent research review, which evalu-
ated the validity of claims of sex differences
regarding genetic effects [50]. The review con-
cluded that most claims concerning sex differ-
ences were insufficiently documented or
spurious, and claims with good documented
internal and external validity were uncommon.
Adding gender theory
To the two-way model, I would also like to add
insights from gender research in understanding
the framework of gender bias in medicine. First,
when discussing why women have been
neglected in research and clinical practice, it is
important to consider the gender order [14],
which in most situations and societies implies
that women are less valued, politically and eco-
nomically influential, and subordinate to men. It
is generally agreed upon that the reason for
selected abortions of female fetuses in large parts
of Asia and North Africa, is that more value is
put into the life of men than the life of
women [51]. Less obvious, but nevertheless simi-
lar attitudes implying neglect and omission of
women, are probably reasons behind that
women receive fewer coronary angiography pro-
cedures than men in the USA [18], or that women
are not offered the same level of care as men
when suffering from psoriasis in Sweden [22].
Second, when trying to understand gender bias
it is relevant to consider the construction of
gender and the continuous ‘doing gender’ proc-
esses [14,15]. Preconceptions about men and
women, their behavior, reactions and needs, con-
tribute to our constructions of gender in everyday
life as well as in medicine. Such preconceptions
also contribute to patients’ help-seeking and risk-
taking behavior as well as in caregivers’ interpreta-
tions of patients’ narratives and conduct. The con-
struction of gender is done in interaction,
involving the patient as well as the doctor or other
caregivers. There are several examples from
research where identical narratives are interpreted
in different ways depending on whether the

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narrator was male or female [7,19,20,52]. Translated
to clinical situations this means that when male
and female patients tell their stories, the doc-
tor, nurse or other member of the healthcare
staff is inclined to interpret even identical narra-
tives in different ways because of assumptions and
preconceived ideas about women and men.
Education requested
Implementation of education about sex- and gen-
der-related processes, reactions, and treatments in
medical school curricula and other forms of health
education is an important step forward in pre-
venting gender bias [53–55]. Yet, as outlined above,
more knowledge does not eradicate the problem
of knowledge-mediated bias or bias owing to
notions and stereotyped ideas about men and
women. Thus, it is also necessary to address atti-
tudes to and preconceptions about men and
women [56,57], and to give the students a chance to
reflect on their own and others interpretations,
reactions and conduct in patient care. This can be
organized by way of group discussions about
paper-cases, role-playing with simulated patients
of different sex, analyses of video consultations, or
in reflective writing. Since gender bias is an unin-
tentional process, it is reasonable to believe that
critical reasoning and reflection are important for
identifying and learning about it.
However, knowledge about the effects of gen-
der perspective in education on students conduct
in medical work is scarce. There is a need for
more research concerning the implementation of
sex- and gender-related knowledge in medical
education, the methods to increase students’
awareness of gender aspects in individual meet-
ings with patients, and specifically the effect the
education has in reducing gender bias in the
medical decision-making of the students.
Future research
Gender bias in healthcare will continue to be an
important research field for years ahead. There is
still the need for descriptive studies about gender
disparities in many specialities, disorders and
countries. There is also a need to learn more
about the cognitive and interaction processes
that lead to gender bias in clinical work, and
gender bias that is built into research designs and
analyses. The following six points summarize the
areas and topics that I regard as most important.
First, despite the insights we already have,
there is a continuous need for research about
gender bias in medical investigations and treat-
ments in everyday clinical practice. Much
remains to be done in all fields of medicine –
even in cardiovascular disease, where the large
bulk of studies have so far been conducted.
There is also a need for the development of fol-
low-up protocols, for regular use in healthcare,
measuring the medical treatment given and the
outcome by gender of patient. Such protocols
might be evaluated on local, regional and
national healthcare levels. Descriptive research
and repeated evaluations are important to pro-
vide new data and ideas for how to prevent and
avoid gender bias.
Second, studies about the cognitive, behavioral
and communication processes creating gender
bias in individual consultations and investigations
have thus far been scarce. Still, knowledge about
such processes is crucial when trying to find ways
to avoid bias and heighten the healthcare workers’
awareness of their own role in the bias process.
Observations of authentic consultations in differ-
ent clinics and contexts would be of certain value.
For this research, qualitative methods such as
action research, analyses of tape recordings and
video filming are suggested. More research grants
have to be allocated for this field.
Third, analyses of sex and gender differences
will continue to be of importance in all health
research, including basic sciences, epidemiology,
clinical trials and health services. This means
that the number of men and women included in
studies must be sufficient to allow for sex- and
gender-based analyses and to assess whether sex,
gender or both are important for the results.
Fourth, in basic science and clinical trials, the
consequences of sociocultural conditions for bio-
logical processes, bodily features and health have
thus far often been overlooked. This means that
gender differences might have been interpreted
as sex differences, in other words, owing to bio-
logy. There is a need for new and reliable designs
and analytical models in research into biological
differences, designs and models that integrate
and consider the impact of sociocultural
conditions on the results.
Fifth, gender blindness and stereotyped pre-
conceptions about men and women are identi-
fied as key causes of gender bias. There is a need
for more research into gender blindness and pre-
conceptions about gender in basic medical con-
cepts and definitions that are taken for granted.
Hitherto such research has mainly been con-
ducted by scholars outside medicine. To increase
the impact of such research within medical sci-
ence, interdisciplinary studies that also involve
medical researchers are welcome.

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242 Women's Health (2008) 4(3) future science group
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Sixth, nowadays, education about sex and gen-
der differences in health is requested in medical
schools. Helping the students avoid making gen-
der-biased assessments, students’ attitudes to and
preconceptions about men and women should
also be addressed. At present, little is known
about the effects of such education. Thus, there is
a great need for scientific evaluations of the
implementation of gender in medical education.
Financial & competing interests disclosure
The author has no relevant affiliations or financial involve-
ment with any organization or entity with a financial interest
in or financial conflict with the subject matter or materials
discussed in the manuscript. This includes employment, con-
sultancies, honoraria, stock ownership or options, expert
testimony, grants or patents received or pending, or royalties.
No writing assistance was utilized in the production of
this manuscript.
Executive summary
• Gender bias means unintended but systematic neglect of either men or women.
• Gender blindness and stereotyped preconceptions about men and women are identified as key causes
to gender bias.
• Exaggeration of observed sex and gender differences can also lead to gender bias.
• ‘Knowledge-mediated’ gender bias implies neglecting patients belonging to the sex in which a
disease is known to be less common or severe.
• The gender order, often implying that women are less valued and influential than men, helps
explaining gender bias.
• ‘Doing gender’ processes mean that healthcare staff is inclined to interpret identical narratives in
different ways for male and female patients.
• Research grants need to be allocated for studies about the cognitive, behavioral and communicating
processes creating gender bias.
• Scientific evaluations are required to determine the effect that gender perspective has in medical
education regarding the tendency to make gender-biased assessments.
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